ACP: Clinical decision support – is it time?

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

The recently enacted American Recovery and Reinvestment Act (ARRA, 2009) and Patient Protection and Affordable Care Act (PPACA, 2010) contain provisions that, if implemented, will fundamentally change the way that medicine will be practiced in the future.

As I indicated in a prior post, the new Center for Medicare and Medicaid Innovation (CMMI) will be testing new delivery models such as the patient-centered medical home (PCMH) and accountable care organizations (ACOs). To achieve the desired goals of improved outcomes and value of care in these models, patient-centered decision making will require enhanced clinical decision support (CDS) that couples patient specific data with the best evidence-based clinical knowledge.

Historically, physicians and health care teams have been trained to intuitively assemble patient data, provide the context to apply clinical knowledge to aid in clinical decisions, and access and apply expert knowledge sources – from the curbside consult to paper and online evidence-based references. As the volume and complexity of biomedical data, information, and clinical knowledge have expanded, the human intuitional capacity to make decisions for and with patients has become increasingly limited.

With these current limitations in mind, what CDS innovations are on the horizon in the Meaningful Use provisions of the HITECH Act to improve clinical decision making — and on a national scale?

Clinical decision support has evolved to CDS “systems” employing machine oriented logic designed to match patient information to a clinical knowledge base, providing the opportunity for patient-centered and patient-specific evaluation and recommendations. As a 2010 AHRQ report cites: “When well designed and implemented, CDS systems have the potential to improve health care quality, and to increase efficiency and reduce health care costs.” For those readers interested in learning more about CDS, The Agency for Healthcare Research and Quality (AHRQ) has an extensive online CDS knowledge library. One useful CDS framework is the Five Rights Model:

The CDS Five Rights Model states that CDS-supported improvements in desired healthcare outcomes can be achieved if we communicate:

1. The right information: evidence-based, suitable to guide action, pertinent to the circumstance

2. To the right person: considering all members of the care team, including clinicians, patients, and their caretakers

3. In the right CDS intervention format: such as an alert, order set, or reference information to answer a clinical question

4. Through the right channel: for example, a clinical information system (CIS) such as an electronic medical record (EMR), personal health record (PHR), or a more general channel such as the Internet or a mobile device

5. At the right time in workflow: for example, at time of decision/action/need

CDS was included in the Stage 1 Meaningful Use Final Rule released in July 2010. That rule required only one CDS rule relevant to a high clinical priority, along with the ability to track compliance with that rule. Last month, the Health IT Policy Committee met to make recommendations to the HHS Secretary on the Medicare and Medicaid EHR incentive programs. The Meaningful Use (MU) Workgroup of the Policy Committee presented their recommendations on requirements, including CDS, that eligible professionals will need to meet to qualify for incentives for certified EHR adoption in Stages 2-3 of MU implementation, beginning in 2012. HHS is expected to publish a request for comment on the draft recommendations in January 2011.

If the Secretary follows the recommendations of the Meaningful Use (MU) Workgroup, it is expected that the CDS recommendations will continue to focus on improving performance on high priority health conditions. As clinicians are in the best position to know the likely benefits and pitfalls of changes in CDS requirements resulting from the implementation of stages 2 and 3 of MU, it will be very important for individual physicians, practice groups and professional medical societies – when the request for comment is released – to comment on the proposed CDS requirements that will lead to the Stage 2 and 3 CDS MU Final Rules.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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